Inflammatory abdominal aortic aneurysm and bilateral complete ureteral obstruction: treatment by endovascular graft and bilateral ureteric stenting

Inflammatory abdominal aortic aneurysms may present a challenge to the surgeon, especially because of associated retroperitoneal fibrosis and possible ureteral complications. We present a case of inflammatory abdominal aortic aneurysm with bilateral ureteral entrapment and complete anuria, successfully treated by endovascular grafting and temporary ureteral stenting.

Invaginating versus classic stripping of the long saphenous vein. A randomized prospective study

Although sound evidence is lacking, many surgeons claim that stripping of the long saphenous vein (LSV) is best performed by invagination. The aim of this prospective, randomized study was to test the hypothesis that invaginating stripping of the LSV is associated with less pain, smaller haematomas and less frequent injury to the saphenous nerve. Thirty patients with bilateral varicose veins and incompetent LSV, but normal short saphenous veins and deep venous systems, were treated by high ligation and stripping of the LSV and multiple stab avulsions. At one side the stripping was performed by invagination (group I), while a classic stripping was done on the other side (group C), so that one leg served as the control of the other. The results were analysed on an intention to treat basis. The median surface of the thigh haematoma between post-operative day seven and ten was 115 cm2 in group I and 135 cm2 in group C (NS). The median pain score was 0.25 and 1.75 respectively (NS). The incidence of saphenous nerve injury was 13% in group I and 17% in group C (NS). At one month 23% of patients stated that the leg with the invaginating stripping had been the more painful, while 33% of patients claimed that the side of the classic stripping had been more painful. The results show that the benefit of invaginating stripping is not as obvious as is generally suggested.

Aneurysm of the iliofemoral vein

In this clinical case we report the use of the superficial femoral vein as an autologous venous interposition graft for the reconstruction of the iliofemoral vein in a 21-year-old female who presented with an asymptomatic primary aneurysm of the left iliofemoral vein. The choice of surgical technique used is discussed.

Experience with cryopreserved arterial allografts in the treatment of prosthetic graft infections

The authors present a retrospective study on 30 patients with prosthetic graft infection. Included are 25 patients with aortic graft infection, three with infection of a femorodistal bypass and two with infected axillofemoral grafts. There were 23 isolated primary prosthetic graft infections and seven aorto-enteric fistulas. Treatment consisted of graft excision and replacement with cryopreserved arterial homografts, harvested from brain-death multi-organ donors. The in situ technique was used in 27 cases. Eight patients died postoperatively and two deaths were from allograft related complications. The operative mortality rate was 11% for isolated aortic graft sepsis and the early limb salvage rate was 100%. Persistent or recurrent infection was noted in two cases. The mean follow-up of the series was 24.5 months and occlusive complications occurred in five patients (23%), which resulted in two major amputations. Serial CT scans showed abnormalities in six of the 22 survivors, all of them related to the aortic segment of the allograft. It is concluded that in situ reconstruction with cryopreserved arterial allografts represents an acceptable alternative, especially in the treatment of isolated aortic graft sepsis. Continued follow-up towards late deterioration and/or occlusive complications remains mandatory.

Classic versus endoscopic perforating vein surgery: a retrospective study

PURPOSE AND METHODS

In this retrospective non-randomized study the results of the FELDER technique (n = 29) were compared to two endoscopic techniques for ligation of incompetent perforating veins: using a mediastinoscope (n = 19) and laparoscopic instruments (n = 57). The indication was a venous ulcer in nine, five and thirteen patients respectively, lipodermatosclerosis in thirteen, five and twenty-four, and simple varicose veins in the remaining patients (NS).

RESULTS

The mean number of interrupted perforating veins was 4.2, 2.4 and 3.8 (p < 0.05). The mean hospital stay was 3.5, 1.9 and 1.6 days (p < 0.0001). The mean period of convalescence was 8.7, 4.1 and 3.7 weeks (NS). The number of complications was 9 (suralis lesion 4, pain/swelling 4, wound problem 1), 6 (saphenous lesion 3, pain/swelling 3) and 15 (pain/swelling 14, deep venous thrombosis 1) (NS). Ten patients were lost to follow-up (five, two and three). Respectively 19, 12 and 45 patients were satisfied with the end-result. The condition had worsened in one, two and three patients (NS). During the short follow-up period all ulcers healed and there was no recurrence.

CONCLUSIONS

The endoscopic techniques produce results comparable to the FELDER procedure, with smaller scars and a tendency towards a faster recovery.

The venous thrombectomy: obsolete or forgotten?

This report describes the surgical management of three patients with an extended ilio-femoral deep venous thrombosis. In the first patient a residual occlusion of the common iliac vein was treated conservatively and this patient developed severe chronic venous insufficiency. In the second patient a residual (sub)occlusion of the common iliac vein was treated with a stent and this patient remained asymptomatic with two years follow-up. In the third patient no residual or underlying anatomical abnormality was found with a good result at one year. Venous thrombectomy still has a place in the treatment of deep venous thrombosis and the long term results may be improved by application of endovascular techniques.

Inflammatory abdominal aortic aneurysms. A retrospective study of 110 cases

OBJECTIVE

The purpose of this study is to review our experience with the surgical treatment of 110 patients with an inflammatory abdominal aortic aneurysm (IAAA). Furthermore, we focus especially on 37 ureteral obstructions.

PATIENTS AND METHODS

Between 1978 and 1996 we treated 110 patients for an IAAA. It concerned 101 men and nine women with mean age of 66.8 years. Emergency surgery was performed in 32 patients (13 ruptures) and elective surgery in 78 patients (only 23 asymptomatic). The IAAA diagnosis was made by CT scan preoperatively in 40% of the patients. Compression of 37 ureters in 23 patients (14 bilateral, 9 unilateral) was noticed and ureteral stenting was performed preoperatively in nine patients (12 ureters). The surgical approach was median laparotomy (88 patients) or retroperitoneal approach (21 patients). One patient was treated with an endovascular Min-Tec Stentor aortic graft by femoral approach. Suprarenal clamping was necessary in 44 patients. Ureterolysis of 23 ureters was performed. Three peroperative iatrogenic lesions were successfully treated intraoperatively.

RESULTS

Fatal complications occurred in nine patients (8%), five patients after urgent surgery and four patients after elective surgery, all of them related to technical problems. Non fatal complications occurred in 22 patients, renal insufficiency was most important in ten patients (two permanent dialysis). The mean follow-up was 4.5 years (range, 0.5 to 15 years). Late survival was 68% at 5 years and 42% after 10 years. Seven patients presented late graft related complications, one fatal. In 14 surviving patients with 21 ureterolysed ureters, one needed a nefrectomy and one a bilateral Boari-plasty. In eight surviving patients with 11 stented ureters, one patient needed a small bowel interposition for ureteral stricture. After CT evaluation, all ureteral stents were removed 3 to 6 months after surgery.

CONCLUSIONS

1. Surgery for IAAA is quite complex. Mortality and morbidity are often associated with emergency or combined vascular and non vascular procedures. 2. When carefull operative repair is performed with minimal dissection of structures from the aneurysmal wall, excellent results can be expected. 3. Ureteral compression should be treated by ureteral stenting, preoperatively, to facilitate ureterolysis or even to avoid it. Regular follow-up CT control is recommended.

The clinical value of duplex surveillance following internal carotid artery reconstruction

BACKGROUND

The purpose of this retrospective analysis was to evaluate the benefit of a yearly duplex ultrasonography of both the reconstructed and the contralateral internal carotid artery (ICA).

METHODS

From 1985 to 1994, 1210 unilateral, primary ICA reconstructions were performed. Although these patients received yearly invitations, duplex follow-up was not available in 114 patients (9%).

RESULTS

At 5 years a stenosis of 50% or more was found in 9% and at 10 years in 14% of patients. During the follow-up period 20 patients developed a stenosis of 80-99%. Ten patients had a redo-procedure. The others remained asymptomatic, even though one patient developed an occlusion. A stroke occurred in 96 patients. 58 of these had no significant stenoses. 57% of all patients had no significant contralateral lesion at the time of the first procedure. In only 4% of these a contralateral CAE was performed during the follow-up.

CONCLUSIONS

In view of the above data, we would conclude that the clinical benefit of duplex surveillance is doubtful.

Transfemoral treatment for iliac occlusive disease with endoluminal stent-grafts

OBJECTIVES

Percutaneous treatment of iliac artery occlusive disease has replaced open vascular reconstruction for several indications. A balloon angioplasty with or without stent is not an option in the presence of infrainguinal extension of the disease. The authors describe a technique that allows the construction of an aorto- or iliofemoral graft through a single groin incision, using a 4 mm PTFE graft, anchoring it proximally with a Palmaz stent and dilating both to the desired diameter.

DESIGN

Retrospective non-randomised study.

MATERIALS AND METHODS

Nineteen procedures were performed in 16 patients mainly because of ischaemic rest pain, often with trophic skin changes or minor gangrene. Three patients had a bilateral procedure. Twelve patients had one or more associated procedures: 10 distal bypasses, one thrombectomy, one reimplantation of a distal bypass on the iliofemoral graft, one contralateral profundaplasty and two stents of the contralateral common iliac artery.

RESULTS

Two patients died, one of small bowel ischaemia and the other of a myocardial infarction. During the mean follow-up of 8.8 months, two graft thromboses occurred. In another patient bilateral stenting of a residual stenosis was necessary.

CONCLUSIONS

Our experience shows that the reported technique is feasible. Whether the procedure is truly "less invasive" and the long-term results acceptable remains to be shown.

Catheter-directed lysis of iliofemoral vein thrombosis with use of rt-PA

The aim of our study was to evaluate the results of catheter-directed thrombolysis and complementary procedures to treat acute iliofemoral deep vein thrombosis (DVT). A total of 24 consecutive patients with acute iliofemoral DVT underwent intrathrombus drip infusion of alteplase (3 mg/h; mean dosage 86 mg, range 45-174 mg), while intravenous heparin (1000 U/h) was continued. Complementary procedures were hydrodynamic thrombectomy in 3 and primary insertion of a Wallstent in 9 patients. Patency of 19 thrombosed veins (79 %) was restored with prompt symptomatic relief. An underlying anatomical anomaly or lesion was present in 13 patients: iliac vein compression syndrome (n = 8), absent (n = 2) or obstructed (n = 1) vena cava or venous stenosis (n = 2). Ten of the abnormalities were unknown before lysis and eight were relieved by stent deployment. Puncture site bleeding was the only complication but led to transfusion in 6 patients (25 %). Symptomatic reocclusion occurred in 4 patients. Catheter thrombolysis of iliofemoral vein thrombosis revealed many anatomical abnormalities which may predispose to thrombosis and are often amenable to stenting.

Stent grafts for iliofemoral occlusive disease

This report summarizes the technical feasibility and early results of endovascular iliofemoral stented grafts in the treatment of iliofemoral occlusive disease. Twenty-four patients (mean age 71 years) underwent 29 lower-extremity inflow procedures for claudication (n = 7) or limb threatening ischaemia (n = 17). The technical success rate for endovascular grafts was 93% (n = 27). Some 85% of the grafts originated from the aortoiliacjunction or the common iliac arteries. Outflow procedures were performed in all cases and consisted of profundaplasty (n = 17) and/or femorodistal grafting (n = 13). The operative mortality rate was 9% and one occlusion was noted in the early postoperative period. The mean (s.d.) primary and secondary cumulative patency rates after 1 year were 85(10)% and 95(5)% respectively. The corresponding limb salvage rate was 95(4)%. The authors conclude that endovascular iliofemoral stented grafts through a single groin incision are technically feasible and that early patency rates are acceptable. More experience is needed however before widespread application of these new techniques can be justified.

Vitamin C supplementation does not modify bone mineral content or mineral absorption in growing pigs

We have demonstrated that alkaline phosphatase activity and collagen synthesis are dose-dependently stimulated by ascorbic acid in differentiated pig osteoblasts. In this study we further examined the relationship between ascorbic acid and bone metabolism by feeding young pigs large amounts of ascorbic acid. Three groups of seven 47-d-old pigs were given no ascorbic acid supplement (control), 500 (500 AA) or 1000 (1000 AA) mg ascorbic acid/kg diet for 4 mo. Calcium and P absorption and retention were evaluated by a 14-d balance trial immediately before killing in control and 1000 AA groups only (n = 6). Bones were collected at death and the bone ash and bending moment (three-point bending test) determined. Various plasma and urine indices of bone metabolism, especially those reflecting collagen degradation (hydroxyproline, deoxypyridinoline) and synthesis (carboxyterminal propeptide of type I collagen) were monitored. The plasma ascorbic acid concentrations increased with time and paralleled the dietary concentrations (P < 0.01). The Ca and P balances and the bone ash and bending moments in the ascorbic acid-supplemented pigs did not differ from those of the controls. Plasma osteocalcin was elevated (P < 0.05), whereas the other bone formation markers, alkaline phosphatase and carboxy terminal propeptide of type I collagen, were not affected by ascorbic acid. The plasma concentrations of Ca, P and 1,25-dihydroxycholecalciferol did not differ among the three groups. The unaffected urinary excretion of deoxypyridinoline and hydroxyproline in the ascorbic acid-supplemented pigs indicates that ascorbic acid does not alter bone resorption. Thus, high intakes of ascorbic acid have no positive influence on bone metabolism and bone characteristics in pigs. The in vivo long-term effects do not correlate with the short-term in vitro effects previously reported.

Ehlers-Danlos syndrome type IV: a heterogeneous disease

The Ehlers-Danlos syndrome is an inherited disorder of connective tissue, consisting of at least 10 different clinical subtypes. Type IV Ehlers-Danlos syndrome is an autosomal dominant condition characterized by the joint and dermal manifestations as in other forms of the syndrome but also by the proneness to spontaneous rupture of bowel and large arteries. The authors describe their experience with three patients presenting type IV Ehlers-Danlos syndrome: the first presented with several subsequent arterial ruptures, the second with multiple aneurysms, and the third with a dissection of the internal carotid artery. Clinical features, incidence, diagnosis, and treatment of the syndrome are discussed.

Recombinant staphylokinase variants with altered immunoreactivity. IV: Identification of variants with reduced antibody induction but intact potency

BACKGROUND

The thrombolytic potency and antibody induction of selected variants of recombinant staphylokinase (SakSTAR), including SakSTAR(K74) with Lys74, SakSTAR(E75) with Glu75-, SakSTAR(EER) with Glu38, Glu75, and Arg77, and SakSTAR(K74ER) with Lys74, Glu75, and Arg77 replaced by Ala, were studied.

METHODS AND RESULTS

In rabbits, SakSTAR(74) and SakSTAR(EER) elicited significantly less circulating neutralizing activity than SakSTAR and SakSTAR(E75) (P = .005 and P = .0002 versus SakSTAR, respectively). In baboons, SakSTAR(K74) induced significantly fewer antibodies than wild-type SakSTAR (P < .05). Intra-arterial administration in patients with peripheral arterial occlusion of SakSTAR(K74) (n = 11) or SakSTAR(K74ER) (n = 6) induced significantly fewer circulating neutralizing antibodies [median values and interquartile ranges, 20 (3.8 to 26) and 2.4 (0.2 to 59) micrograms compound neutralized/mL plasma after 3 to 4 weeks (P = .01 and P = .035 versus SakSTAR, respectively)] than SakSTAR (n = 9) [median value and interquartile range, 93 (24 to 110) micrograms compound neutralized/mL plasma]. Overt neutralizing antibody induction (> 10 micrograms compound neutralized/mL plasma) occurred in all 9 patients given wild-type SakSTAR, in 6 of the 11 SakSTAR(K74ER) patients (P = .038 versus SakSTAR), and in 2 of the 6 SakSTAR(K74ER) patients (P = .011 versus SakSTAR).

CONCLUSIONS

SakSTAR(K74), a variant of recombinant staphylokinase with a single substitution of Lys74 with Ala, and SakSTAR(K74), with Lys74, Glu75, and Arg77 substituted with Ala, have intact thrombolytic potencies but induce significantly less antibody formation in patients.

The value of carotid stump pressure and EEG monitoring in predicting carotid cross-clamping intolerance

The authors analyse their experience with carotid stump pressure (CSP) and electro-encephalogram (EEG) monitoring in relation to the incidence of peroperative stroke during internal carotid artery reconstruction. A series of 215 patients is presented, among whom six (2.8%) developed a peroperative stroke. The stroke rate in patients with a CSP below 50 mm Hg (n = 92) was 7% (2/27) without a shunt and 3% (2/62) with the use of a shunt. The respective numbers for patients with a CSP equal to or above 50 mmHg were 1.7% (2/123) and 0% (0/10). The EEG remained normal after cross clamping in 180 cases (84%): the incidence of stroke was 1.5% (2/138) without and 5% (2/42) with a shunt. A shunt was used in 33 of the 35 patients with EEG changes after cross clamping. None of them sustained a stroke in contrast to both patients where despite EEG changes no shunt was used (respective stroke rates 0% and 100%). It is concluded that regarding cerebral function, EEG monitoring provides more accurate information than CSP.

Phase I/II study of gemcitabine and cisplatin in the treatment of advanced non-small cell lung cancer: preliminary results

Sixty-six patients with advanced non-small cell lung cancer have been entered into a phase I/II study of a combination of gemcitabine and cisplatin. An initial phase I portion of the study has been completed, and 16 patients have been entered using a fixed dose of gemcitabine 1,000 mg/m2 as a 30-minute intravenous infusion weekly for 3 weeks. Cisplatin was administered on day 15 following gemcitabine with appropriate prehydration and posthydration. The study was designed to allow for sequential groups of three patients to receive three dose levels of cisplatin (60 mg/m2, 75 mg/ m2, and 100 mg/m2). Dose modification and patient numbers were to be increased at any dose level if significant toxicity was observed. The regimen was well tolerated at all doses, and the final level of cisplatin 100 mg/m2 was expanded to 10 patients before the phase II portion was opened. Neutropenia (World Health Organization grade 4 in three patients) and thrombocytopenia (grade 3 or 4 in five patients) were the main hematologic toxicities recorded. These episodes were brief and uncomplicated. Grade 3 nausea and vomiting occurred in 12 patients, but was no worse than would be expected from cisplatin alone. Alopecia, when it occurred, was minimal (no hair loss in 10 patients and grade 1 or 2 in six patients). No significant renal toxicity or neurotoxicity was seen. A phase II study with cisplatin 100 mg/m2 and gemcitabine 1,000 mg/m2 has been opened, and to date 43 patients are evaluable for response. Eighteen (42%) patients have achieved partial remissions. The study will close when 50 evaluable patients have been entered.

[Percutaneous intentional extraluminal recanalization of the femoropopliteal artery. Initial experiences and results]

Between July 1994 and April 1995, 14 patients with a chronic occlusion of the femoropopliteal artery were treated by percutaneous intentional extraluminal recanalisation (PIER). It concerned 11 males and 3 females with a mean age of 65 years (50-76 years). Twelve patients were smokers, two patients had diabetes mellitus. Ten patients had severe claudication, four patients suffered from rest pain, three of the latter had ulcerations. In all patients, recanalisation and balloon dilatation could be established. However, angiographic result was unsatisfactory in one case. There were no complications. Clinical follow-up varied from 2 weeks to 9 months. Two patients needed a surgical femoropopliteal bypass respectively 4 and 7 months after recanalisation because of claudication recurrence. A third patient had two percutaneous redilatations of a restenosis. The remaining 11 patients became free of complaints. PIER seems to be a feasible treatment for patients with chronic femoropopliteal occlusions with a very good technical success, low complication rate and promising initial clinical outcome. Follow-up studies have to prove its superiority over the established revascularisation techniques.

Microbiological monitoring of aortic aneurysm sac contents during abdominal aneurysmectomy: results in 176 patients and review of the literature

To investigate the clinical significance of intraoperative cultures, aneurysmal thrombus was cultured in 176 patients with clinically non suspected infected abdominal aortic aneurysm. The incidence of positive cultures was 14.2% and 88% of the microorganisms were Gram-positive. Differences between elective and urgent reconstruction were not significant. During follow-up, there were no cases of graft infection in either group. Review of the literature shows a positive culture rate of 19% in a series of 1867 patients. 93% Of the microorganisms are Gram-positive and 78% are considered as contaminants. The incidence of graft infection is 1.99% in the group with positive culture and 0.7% in the series with negative culture (P = 0.06). It is concluded that the clinical significance of routine cultures in clinically non suspected infected aortic aneurysms is negligible.

Carotid surgery in octogenarians: is it worthwhile?

Controversy surrounds the role of carotid endarterectomy in octogenarians. Although the prognosis of severe degree carotid stenosis is more ominous in the elderly, operative risk seems more important in the aged. To evaluate the presumed detrimental effect of advanced age on the mortality-morbidity of carotid endarterectomy, the authors reviewed their common experience with carotid surgery in patients aged 80 years or more. From 1980 to 1994, 129 octogenarians were operated on for occlusive carotid artery disease in two university hospitals. The data for these patients, 80 years of age and older (group 1) are compared to these for a large middle age group (less than 80 years) (group 2) operated by the same surgeons during that period. The baseline characteristics of both groups were similar, except for smoking, diabetes and previous myocardial revascularization, more prevalent in the younger age group. In the elderly group prophylactic surgery for asymptomatic stenosis was done in 36%, versus 40% of the middle aged patients, and for stroke in evolution in 8% versus 4% (p < 0.05). The perioperative stroke rate was 0.8% in the group older than 80 years, compared to 1.2% for non octogenarians (NS). The operative mortality was similar for both age groups (2.3 and 1.5 respectively). The long-term results gave a similar outlook for both age groups. The 5-year stroke-free rate reached 89% for group 1 versus 91% for group 2. The 5-year survival rate, however, was less for the elderly patients (47% versus 77%, mean follow-up periods of 30 and 49 months). These results suggest that carotid endarterectomy can be safely done in elderly patients, with a similar risk/benefit ratio as for the younger patients. Advanced age, by itself, is not to be considered as contraindication to carotid surgery.

Supra- and juxtarenal aneurysms of the abdominal aorta: preoperative assessment with thin-section spiral CT

PURPOSE

To assess the contribution of thin-section spiral computed tomography (CT) to the preoperative radiologic evaluation of juxta- and suprarenal abdominal aortic aneurysms.

MATERIALS AND METHODS

Thirty-eight patients (26 men, 12 women; age range, 60-81 years) with infrarenal (n = 23), juxtarenal (n = 8), and suprarenal (n = 7) aneurysms underwent digital subtraction angiography (DSA) and 2-mm-collimation spiral CT. Cine-interactive display of overlapping axial, reformatted, and maximum intensity projection images were used for CT image analysis. CT findings were compared with angiographic and surgical findings.

RESULTS

The proximal extent of the juxta- and suprarenal aneurysms (n = 15) could be correctly predicted in 12 cases (80%) with DSA and was exactly determined in 14 (93%) with CT. All renal arteries except three accessory renal arteries were correctly depicted with spiral CT (83 of 86 [96%]). With DSA as the standard of reference, renal artery stenoses of at least 70% were accurately assessed in 95% of cases.

CONCLUSION

Thin-section spiral CT can provide additional information in the preoperative diagnosis of juxta- and suprarenal aneurysms.

Technique and early results of videoscopic lumbar sympathectomy

The authors describe their technique of videoscopic (VS) lumbar sympathectomy (LSE), compared to the open LSE. From 1992 to 1994, 21 open and 19 VS LSE were performed. The indication was reflex sympathetic dystrophy in 17 and arterial insufficiency in 23 patients. In the open LSE the mean duration of anaesthesia was 80 min (55-115) and of surgery 37 min (25-65). The length of the chain removed varied from 1 to 3 ganglia (6-7 cm). Complications were noted in 5 patients: 1 pneumonia, 2 superficial wound problems and 2 cases of postsympathectomy neuralgia. Hospital stay of patients with RSD varied from 2 to 5 days. Of the 19 attempts to perform a VS LSE 4 had to be converted to the open technique. The duration of anesthesia was 150 min (90-280) and of surgery 92 min (45-240). Lengths of chain removed varied from 1 to several ganglia (6-7 cm). A pneumoperitoneum was present in 10 procedures, but a Veress needle was placed in only 4 of these. Complications were present in 9 patients: 1 important subcutaneous emphysema, 1 severe costal pain, 2 neuralgia, 1 temporary psoas dysfunction, 1 haemorrhage from a lumbar vein with conversion to the open technique and 3 minor superficial wound problems. The hospital stay ranged from 2 to 5 days. This study suggests that the VS LSE has no benefit over the open technique as far as the operative and early results are concerned. Whether this technique avoids some of the late disadvantages of a lumbotomy remains to be seen.

Proximal migration of vena caval filters: report of two cases with operative retrieval

Operative retrieval of two proximally migrated vena caval filters was performed in two patients, ages 42 and 45 years, respectively. In the first patient the filter was encrusted in the right ventricle, and in the second one the filter was found in the pulmonary artery. Both filters were retrieved under cardiopulmonary bypass via an incision in the right atrium and the pulmonary artery, respectively. These two observations underscore the risk of increased unwarranted indications and consequent higher complication rates of vena caval filters.

Thrombolytic therapy of peripheral arterial occlusion with recombinant staphylokinase

BACKGROUND

Recombinant staphylokinase (STAR) induces fibrin-specific coronary artery recanalization in patients with evolving myocardial infarction. The present pilot study evaluates its thrombolytic efficacy, safety, fibrin specificity, and immunogenicity in patients with peripheral arterial occlusive disease.

METHODS AND RESULTS

Thirty patients (37 to 86 years of age) with angiographically documented thromboembolic peripheral arterial occlusion of recent origin (21 +/- 5.5 days, mean +/- SEM) were treated with heparin and intra-arterial STAR given as a 1-mg bolus followed by a 0.5-mg/h infusion in 20 patients or as a 2-mg bolus followed by a 1-mg/h infusion in 10 subsequent patients. With 7.0 +/- 0.7 mg STAR infused over 8.7 +/- 1.0 hours, recanalization was complete in 25 patients, partial in 2, and absent in 3. Two major hemorrhagic complications occurred: one fatal hemorrhagic stroke and one hypovolemic shock caused by bleeding at the angiographic puncture site. Administration of STAR did not induce fibrinogen breakdown or a significant prolongation of template bleeding time. STAR-neutralizing activity and anti-STAR IgG were low at baseline, increased markedly from the second week on, and remained elevated for several months.

CONCLUSIONS

Intra-arterial administration of STAR restores vessel patency in patients with peripheral arterial occlusion in the absence of fibrinogen degradation.